Implementing an innovation to improve coordination of care in breast cancer.

Abstract

52 Background: Underuse of adjuvant breast cancer treatments delivered by different specialists may be worsened by fragmented care and improved by effective coordination. To improve care coordination and adjuvant treatment delivery, we assessed the challenges to and feasibility of implementing a web-based Tracking and Feedback (T&F) innovation in hospitals serving predominantly minority breast cancer patients. Methods: We interviewed 67 key informants [Clinical (n = 39), Administrative (n = 14), Clerical (n = 11), Other (IT, Social Work) (n = 3)] from 8 inner-city hospitals to better understand how organizational characteristics might impact coordination of care and implementation of the T & F innovation. We used the constant comparative method of qualitative data analysis and standard techniques to code the data. Results: We found considerable variability across hospitals’ abilities to coordinate and track care. All sites have multi-disciplinary Tumor Board meetings and active Quality Improvement departments. Yet, in several sites, specialty care remains siloed, quality improvement efforts focus on inpatient care and communications systems across outpatient specialties are poor. All hospitals have electronic medical records but they are not integrated and are unable to track requested referrals. Many physicians rely on follow-up appointments to ascertain treatment receipt but sites vary in their ability to address “no-shows.” Several rely on staff to manually identify and follow up “no-shows,” but many of these staff are overwhelmed with ever increasing tasks and responsibilities. While quality was important, several interviewees felt they were bucking an inflexible system and devised ways to work around the obstacles. Perceived successful coordination factors included strong clinical leadership, designated accountabilities, and flexibility of staff. Conclusions: As care integration is encouraged by federal law, specialty care silos and rigid communication systems still pose barriers to change. Our results suggest that a web-based T&F innovation must be tailored to individual hospital characteristics, and flexible to permit modification of care processes at the organization level. Clinical trial information: NCT01544374.